Author Information

1 Introduction

1.1 Document Development Process

1.1.1 Writing Committee Organization

The writing committee was selected to represent the American College of Cardiology (ACC) and included a cardiovascular training program director; a director of a coronary care unit; experts in advanced interventional procedures, cardiothoracic surgery, electrophysiology, and heart failure; early-career experts; highly experienced specialists representing both the academic and community-based practice settings; and physicians experienced in defining and applying training standards according to the 6 general competency domains promulgated by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) and endorsed by the American Board of Internal Medicine (ABIM). The ACC determined that relationships with industry or other entities were not relevant to the creation of this cardiology training statement. Employment and affiliation details for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document.

1.1.2 Document Development and Approval

The writing committee developed the document, approved it for review by individuals selected by the ACC, and then addressed the reviewers’ comments. The document was revised and posted for public comment from December 20, 2014, to January 6, 2015. Authors addressed these additional comments from the public to complete the document. The final document was approved by the Task Force, COCATS Steering Committee, and ACC Competency Management Committee, and ratified by the ACC Board of Trustees in March, 2015. This document is considered current until the ACC Competency Management Committee revises or withdraws it.

1.2 Background and Scope

The field of critical care cardiology has evolved considerably over the past 2 decades. The coronary care unit of the 1970s and 1980s was populated most frequently by patients with acute—and often uncomplicated—myocardial infarction or unstable angina. Detection and rapid treatment of arrhythmias were the primary goals of therapy. Today, patients with acute coronary syndromes, including those with ST-elevation myocardial infarction who have undergone primary percutaneous coronary intervention, may be managed at some institutions in step-down units with continuous telemetry monitoring. At all institutions, contemporary critical care cardiology is increasingly focused on the management of patients with advanced hemodynamic compromise, complex ventricular arrhythmias, and established or incipient multiorgan failure, thus demanding a broader and more in-depth knowledge base and refined skill set than that expected of care providers in years past. In addition, at many institutions, increasing numbers of patients undergoing transcatheter valve therapies or ventricular assist devices are cared for in cardiac intensive care units. A premium is placed, not only on the ability to participate in or lead interdisciplinary care teams in this environment, but also on the skills needed to ensure orderly transitions of care once patients are ready for transfer to less intensive hospital units or directly to a rehabilitation facility. The competencies important for the cardiovascular medicine fellow to achieve during critical care cardiology training have not been included in previous iterations of COCATS and are provided here in recognition of the need to define them within the context of this evolving and complex field. Many of the competencies pertinent to critical care cardiology will be acquired during other rotations; these include cardiac catheterization, electrophysiology, and advanced heart failure.

In addition, this report addresses the evolving framework of competency-based medical education described by the ACGME Outcomes Project and the 6 general competencies endorsed by ACGME and ABMS. The background and overarching principles governing fellowship training are provided in the COCATS 4 Introduction, and readers should become familiar with this foundation before considering the details of training in a subdiscipline like critical care cardiology. The Steering Committee and Task Force recognize that implementation of these changes in training requirements will occur incrementally.

For most areas of cardiovascular medicine, 3 levels of training are delineated:

▪ Level I training is the basic training required to become a competent cardiovascular consultant. This level of training is required of all cardiovascular fellows and can be accomplished as part of a standard 3-year training program in cardiovascular medicine. Cardiovascular fellows should be well equipped to manage the majority of patients in a critical care cardiology environment.

▪ Level II training refers to additional training in 1 or more areas that enables some cardiovascular specialists to perform or interpret specific diagnostic tests and procedures or render more specialized care for patients and conditions. This level of training is recognized for those areas in which an accepted instrument or benchmark, such as a qualifying examination, is available to measure specific knowledge, skills, or competence. Level II training in selected areas may be achieved by some trainees during the standard 3-year cardiology fellowship, depending on the trainee’s career goals and use of elective rotations. It is anticipated that during a standard 3-year cardiovascular fellowship training program, sufficient time will be available for trainees to receive Level II training in a specific subspecialty. Additional training of this type would signify a strong career interest in critical care cardiology. There are currently challenges to measurement and verification of these additional competencies that require further adjudication. Although some fellows may obtain enhanced procedural skills in the context of a 3-year cardiovascular medicine fellowship by spending additional time (3 to 6 months) dedicated to critical care cardiology experiences, there is currently no Level II designation in this field of cardiology.

▪ Level III training requires advanced training and experience beyond the cardiovascular fellowship to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific procedures or render advanced specialized care at a high level of skill. For critical care cardiology, Level III training involves completion of a 1-year clinical fellowship in critical care medicine within the Department of Medicine in addition to the 3-year cardiovascular medicine fellowship (1).

2 General Standards

The essentials of critical care cardiology should be taught to all fellows. Critical care training should be integrated into the fellowship program and should include the evaluation and management of patients with acute, life-threatening cardiovascular illnesses; exposure to noninvasive and invasive diagnostic modalities commonly used in the evaluation of such patients; familiarity with both temporary and long-term mechanical circulatory support devices; and an understanding of the management of critically ill patients. The majority of critical care cardiology training will occur during dedicated rotations in the cardiac intensive care unit as well as in the cardiac surgical intensive care unit; however, knowledge and skills relevant to critical care cardiology will also be integral components of other rotations, such as electrophysiology (see COCATS 4 Task Force 11 report), advanced heart failure and transplantation (2) (see COCATS 4 Task Force 12 report), cardiac catheterization (see COCATS 4 Task Force 10 report), and imaging (see COCATS 4 Task Force 4 to 8 reports). Acquiring this fundamental knowledge will permit the fellow to diagnose a broad array of cardiovascular disorders, initiate appropriate medical management, and consult when necessary with other specialists to enable further evaluation and treatment. Importantly, the fellow will acquire the skills necessary to work with other care team members in the interdisciplinary management of critically ill patients and demonstrate competency in ensuring safe and orderly transitions of care. These recommendations are congruent with other training documents and address faculty and facility requirements, emerging technologies, and practice (1,3,4). We recommend that candidates for the ABIM examination for certification in cardiovascular diseases, as well as those seeking certification of added qualifications in critical care, review the specific requirements of the ABIM.

Cardiovascular fellowship programs should satisfy the requirements regarding faculty and facilities for training in critical care cardiology. Eligibility for the ABIM examination requires that training take place in a program accredited by the ACGME. The intensity of training and required resources vary with the level of training provided.

2.1 Faculty

Faculty should include dedicated cardiovascular specialists with extensive critical care experience as well as representatives from several cardiovascular specialty disciplines necessary for an interdisciplinary approach to critical care. Cardiovascular critical care specialists should possess adequate knowledge of pharmacological, device-based, and surgical therapies relevant to the field of critical care cardiology. Relevant faculty from various cardiovascular specialties participating in critical care training should include general cardiologists, electrophysiologists, coronary and structural interventionists, heart failure specialists, and surgeons (including those with knowledge of or specialization in the application of advanced hemodynamic support of critically ill patients). Other faculty expected to contribute to the care of critically ill cardiovascular patients include those with expertise in nephrology, neurology, pulmonary medicine, infectious diseases, gastroenterology, hematology, and anesthesiology. The cardiovascular critical care team also includes representation from nursing, pharmacy, respiratory care, nutrition, dialysis, physical/occupational therapy, social work, and hospital ethics committees, among others. All team members contribute to training the cardiovascular fellow in this environment.

There must be at least 1 key clinical faculty member dedicated to training fellows in critical care cardiology. This faculty member should be board-certified in cardiology and demonstrate that she/he is meeting requirements for maintenance of certification. In most instances, this individual will serve as the medical director of the critical care cardiology unit and will assume responsibility for curriculum development and oversight, working in collaboration with the training program director. Sufficient numbers of qualified faculty experts in critical care cardiology must exist to provide direct supervision of all fellows as fellows rotate through the cardiac critical care unit. Critical care faculty should have sufficient experience with the indications for and contraindications to bedside diagnostic and treatment procedures to allow them to independently supervise fellows in their performance (see COCATS 4 Task Force 10 and 11 reports).

2.2 Facilities

Facilities should be adequate to ensure a safe, supportive, efficient, and effective environment for the provision of critical care services to an increasingly complex patient population. The cardiac care unit must be of sufficient size to serve the patient load, with adequate space in each room as determined by staff and equipment needs. Providing separate rooms for each patient is optimal and isolation rooms either within or immediately available to the unit should be utilized as necessary. Sufficient workspace to accommodate staff functions, preferably in a centralized location allowing direct or indirect visualization of all patients at all times, is necessary. To augment routine monitoring of each patient, facilities should include appropriate equipment in each room and at the nursing station. Additional space and resources required for the safe performance of invasive procedures in the cardiac critical care unit (e.g., pulmonary artery catheter or temporary pacemaker placement) should be available.

2.3 Equipment

The critical care unit should be equipped to provide comprehensive bedside monitoring and support. Requirements include continuous electrocardiographic monitoring; invasive arterial, venous, and pulmonary arterial pressure monitoring; oxygen saturation monitoring; bedside imaging; mechanical circulatory support devices; and mechanical ventilator support devices. Equipment should be available for systemic cooling as part of hypothermia protocols and for renal replacement therapy when required. Electronic health record resources should be available to organize patient-related data efficiently and enhance communication among members of the critical care team.

2.4 Ancillary Support Capabilities

Ancillary support should be available to care for critically ill cardiovascular patients, including on-site access to all core cardiovascular and imaging services. These services include cardiac catheterization, echocardiography, and electrophysiology facilities, as well as comprehensive radiology services for brain, vascular, thoracic, abdominal, and pelvic imaging. Required support services also include cardiac surgery, anesthesia, endovascular and interventional radiology, vascular surgery, neurology, nephrology, pulmonary, social work, ethics, palliative care, and pharmacy services with “24/7/365” availability.

3 Training Components

3.1 Didactic Program

An important aspect of training in critical care cardiology is didactic instruction. Didactic sessions can occur in a variety of formats, including but not limited to lectures, conferences, journal clubs, grand rounds, and clinical case presentations. The majority of case-based teaching for critical care cardiology will occur during scheduled rotations in the critical care unit, but such teaching need not be limited to this care site. Rather, teaching that is relevant to the care of critically ill patients will occur throughout the fellowship training program.

3.2 Clinical Cases

Trainees should gain firsthand experience in the evaluation and management of critically ill cardiac patients during unit rotations that include a minimum exposure of 8 (not necessarily consecutive) weeks during the first 24 months of training. Exposure should allow the trainee to obtain the knowledge and skills required to manage the broad spectrum of acute coronary syndromes, mechanical complications of myocardial infarction, acutely decompensated severe heart failure, severe pulmonary hypertension with/without right ventricular failure, circulatory collapse/shock, acute severe heart valve disorders, pericardial tamponade, aortic dissection, hypertensive emergencies, massive or submassive pulmonary embolism, and life-threatening arrhythmias and cardiac conduction disorders. During this exposure, the trainee is expected to demonstrate understanding of and apply the findings from invasive hemodynamic monitoring to patient care and to recognize the indications for advanced interventional or surgical treatments, including mechanical circulatory support, coronary artery bypass grafting, percutaneous coronary intervention, heart valve repair/replacement (including transcatheter techniques), pericardiocentesis, open or endovascular aortic repair, and pulmonary embolectomy or fragmentation. The cardiac critical care unit experience should include opportunities to participate in and, when appropriate, lead interdisciplinary care teams, as noted in Section 2.1.

3.3 Hands-On Experience

Level 1 trainees should demonstrate knowledge and make appropriate use of medications necessary for the treatment of critically ill cardiac patients, including but not limited to inotropic, vasopressor, vasodilator, fibrinolytic, anticoagulant, antiplatelet, antiarrhythmic, sedative, analgesic, and paralytic agents. In addition, over the 24 months of clinical training—and in sequence with cardiac catheterization laboratory rotations—all trainees should develop the skills necessary to insert central venous lines, temporary transvenous pacemakers, radial arterial lines, and balloon-flotation pulmonary artery catheters. All of these procedures may be performed at the bedside. Trainees should recognize the indications for endotracheal intubation, mechanical ventilation, and renal replacement therapy and demonstrate the skills needed to evaluate and treat spontaneous or treatment-related acute bleeding complications. Level I trainees should know the indications for mechanical circulatory support, including intra-aortic balloon counterpulsation and ventricular assist devices (5,6). These trainees should have the skill to utilize therapeutic hypothermia for victims of out-of-hospital cardiac arrest, should demonstrate an understanding of how to integrate palliative and hospice care, and identify when further care is futile. Trainees should also develop the knowledge and skills needed to ensure appropriate transitions of care.

4 Summary of Training Requirements

4.1 Development and Evaluation of Core Competencies

Training and requirements in critical care cardiology address the 6 general competencies promulgated by the ACGME/ABMS and endorsed by the ABIM. These competency domains are: medical knowledge, patient care and procedural skills, practice-based learning and improvement, systems-based practice, interpersonal and communication skills, and professionalism. The ACC has used this structure to define and depict the components of the core clinical competencies for cardiology. The curricular milestones for each competency and domain also provide a developmental roadmap for fellows as they progress through various levels of training and serve as an underpinning for the ACGME/ABIM reporting milestones. The ACC has adopted this format for its competency and training statements, career milestones, lifelong learning, and educational programs. Additionally, it has developed tools to assist physicians in assessing, enhancing, and documenting these competencies.

Table 1 delineates each of the 6 competency domains as well as their associated curricular milestones for training in critical care cardiology. The milestones are categorized into Level I and III training (as previously defined in this document) and indicate the stage of fellowship training (12, 24, or 36 months, and additional time points) by which the typical cardiovascular trainee should achieve the designated level. Given that programs may vary with respect to the sequence of clinical experiences provided to trainees, the milestones at which various competencies are reached may also vary. Level I competencies may be achieved at earlier or later time points. Acquisition of Level III skills requires training in a dedicated critical care cardiology program. The table also describes examples of evaluation tools suitable for assessment of competence in each domain.

4.2 Number of Procedures and Duration of Training

The specific competencies for Levels I and III are delineated in Table 1. Level I competencies must be obtained by all fellows during the 3-year cardiovascular disease fellowship training program. The minimum duration of training for Level I competencies is 8 weeks over the course of the first 24 months of training. Specific procedural volume targets are not provided. Many of these will be obtained during other rotations, such as cardiac catheterization and electrophysiology. Nevertheless, outcomes-based evaluation measures must demonstrate that such competencies have been achieved. Designation of Level II competencies will require further clarification once additional experience is gained with the critical care cardiology pathway. Level III competencies are noted so that fellows are aware of the competencies for which additional, advanced training beyond the standard 3-year fellowship is required. Level III training could be accomplished with a dedicated year of critical care medicine training, in conjunction with the Department of Medicine at the sponsoring institution. A brief discussion of the competencies and training requirements for Levels I, II, and III follows. Although the minimum training duration and numbers of procedures are typically required to obtain competency, trainees must also demonstrate achievement of the competencies as assessed by the outcomes evaluation measures.

4.2.1 Level I Training Requirements

Level I training will typically require at least 8 weeks of cardiology critical care exposure designed to allow the trainee to acquire the knowledge, skills, and experience necessary to achieve the competencies listed in Table 1. Because both dedicated critical cardiology time and complementary experiences necessary to gain knowledge and skills through other cardiovascular rotations may be assigned at various times to trainees over the first 24 months of training, the milestones for the relevant competencies should be reached by 24 months.

4.2.2 Future Level II Training Requirements

Level II training will involve more advanced knowledge and skills than Level I training, likely with greater experience with bedside procedures and the skills needed for leading interdisciplinary teams managing critically ill patients, but not with the competency expected with Level III training. Preliminarily, an additional 3 to 6 months of clinical training within the 3-year cardiovascular medicine fellowship is envisioned to acquire these skills, but at present Level II training in critical care cardiology is not recognized.

4.2.3 Level III Training Requirements

Level III training prepares the physician to specialize in critical care cardiology. Level III requires additional experience beyond the standard 3-year cardiovascular fellowship for the trainee to acquire specialized knowledge and competencies in performing, interpreting, and training others to perform specific critical care functions and procedures or render advanced, specialized critical care at a high level of skill. Trainees should obtain additional critical care medicine training within the department of medicine upon completing a 3-year cardiovascular fellowship. A portion of this advanced training can be spent under supervision in cardiac or cardiac surgical intensive care units, as specified by the critical care medicine fellowship program. Level III training is described here only in broad terms to provide context for trainees and clarify that these advanced competencies are not covered during the general cardiology fellowship. The additional exposure and requirements for Level III training will be addressed in a subsequent, separately published Advanced Training Statement.

5 Evaluation of Competency

Evaluation tools in critical care cardiology include direct observation by instructors, in-training examinations, case logbooks, conference and case presentations, multisource evaluations, trainee portfolios, and simulation. Case management, judgment, interpretive, and bedside skills must be evaluated in every trainee. Quality of care and follow-up; reliability; judgment, decisions, or actions that result in complications; interaction with other physicians, patients, and laboratory support staff; initiative; and the ability to make appropriate decisions independently should be considered. Trainees should maintain records of participation and advancement in the form of a Health Insurance Portability and Accountability Act (HIPAA)–compliant electronic database or logbook that meets ACGME reporting standards and summarizes pertinent clinical information (e.g., number of cases, diversity of referral sources, diagnoses, disease severity, outcomes, and disposition).

Under the aegis of the program director, the faculty should record and verify each trainee’s experiences, assess performance, and document satisfactory achievement. The program director is responsible for confirming experience and competence and reviewing the overall progress of individual trainees with the Clinical Competency Committee to ensure achievement of selected training milestones and to identify areas in which additional focused training may be required.

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects authors’ employment and reporting categories. To ensure complete transparency, authors’ comprehensive healthcare-related disclosure information—including relationships with industry not pertinent to this document—is available in an online data supplement. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees.

For the purpose of developing a general cardiology training statement, the ACC determined that no relationships with industry or other entities were relevant. This table reflects peer reviewers’ employment, representation in the review process, as well as reporting categories. Names are listed in alphabetical order within each category of review. Please refer to http://www.acc.org/guidelines/about-guidelines-and-clinical-documents/relationships-with-industry-policy for definitions of disclosure categories, relevance, or additional information about the ACC Disclosure Policy for Writing Committees.

(2012) Evolution of critical care cardiology: transformation of the cardiovascular intensive care unit and the emerging need for new medical staffing and training models: a scientific statement from the American Heart Association. Circulation126:1408–1428.

(2013) Organization and staffing practices in U.S. cardiac intensive care units: a survey on behalf of the American Heart Association Writing Group on the Evolution of Critical Care Cardiology. Eur Heart J Acute Cardiovasc Care2:3–8.

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